Crossroads Counseling PLLC 3550 Parkwood Blvd. Suite 401Frisco, TX 75034 Page 1 Alexandria Pena, MS, LPC-Intern Supervised by Patti Doumany, MEd, LPC-S, RPT-S Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 4090, Frisco, TX 75034 940-300-1706 GENERAL INTAKE INFORMATION Today’s Date: __________________ Child’s Name: ___________________________________________________________ Guardian(s): (Who child is living with _________________________________________ Referred by: ____________________________________________________________ Child’s date of birth: __________________ Age:__________ Gender: M F Home Address: _________________________ _________________ _____________ street city zip May we communicate with you by mail at this address? __________________________ Preferred guardian contact: ________________________________________________ Home Phone #:_______________________ Cell Phone: ________________________ Work Phone: ___________________________ May we contact you at Work? Y N May we leave you a message? Home phone: ____ Cell phone: ____ Work phone: ____ Email address: _________________________________________________________ Emergency Contact: _______________________________ ph.#___________________ (Signature at end of document indicates consent to contact this person in the rare case of an emergency.) School child is attending: ______________________________________ Grade: _____ Main Teacher: ___________________________ Current School Grades: ___________ Is your child receiving special education or other special services at school? Y N If yes, please explain. _____________________________________________________ Date of Last Physical: __________ Primary Care Physician: ______________________ Current diagnosis or medical concerns: _______________________________________ _______________________________________________________________________ Please list all current medications and dosages: ________________________________ ______________________________________________________________________ Did your child experience any developmental delays in the following areas? (Circle) Physical: N Y Speech: N Y Social: N Y Emotional: N Y If yes, please describe: ___________________________________________________ Briefly describe why you are seeking counseling for your child: ____________________
Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 4090, Frisco, TX 75034 940-300-1706
GENERAL INTAKE INFORMATION
Today’s Date: __________________ Child’s Name: ___________________________________________________________ Guardian(s): (Who child is living with _________________________________________ Referred by: ____________________________________________________________ Child’s date of birth: __________________ Age:__________ Gender: M F Home Address: _________________________ _________________ _____________ street city zip May we communicate with you by mail at this address? __________________________ Preferred guardian contact: ________________________________________________
Home Phone #:_______________________ Cell Phone: ________________________ Work Phone: ___________________________ May we contact you at Work? Y N May we leave you a message? Home phone: ____ Cell phone: ____ Work phone: ____ Email address: _________________________________________________________ Emergency Contact: _______________________________ ph.#___________________ (Signature at end of document indicates consent to contact this person in the rare case of an emergency.) School child is attending: ______________________________________ Grade: _____ Main Teacher: ___________________________ Current School Grades: ___________ Is your child receiving special education or other special services at school? Y N If yes, please explain. _____________________________________________________ Date of Last Physical: __________ Primary Care Physician: ______________________ Current diagnosis or medical concerns: _______________________________________
_______________________________________________________________________ Please list all current medications and dosages: ________________________________
______________________________________________________________________ Did your child experience any developmental delays in the following areas? (Circle) Physical: N Y Speech: N Y Social: N Y Emotional: N Y If yes, please describe: ___________________________________________________
Briefly describe why you are seeking counseling for your child: ____________________
______________________________________________________________________ How would you rate the intensity of the problem or concern? (1 = NOT intense……….10 = VERY intense) 1 2 3 4 5 6 7 8 9 10
Past Counseling History: Date Length of Service Agency and Therapist Providing Service ________ ____________________ ___________________________________
________ ____________________ ___________________________________ Child’s current household: ___ Natural parents ___ Father only ___ Mother only ___ Adoptive parents ___ Relatives ___ Foster family ___ Natural father and stepmother ___ Natural mother and stepfather ___ Other
Primary Household (anyone currently living with child)
Name Age Gender Relationship ___________________________ ____ _____ ________________________
Has your child ever talked about hurting or killing himself/herself or another person? Please describe: ________________________________________________________
______________________________________________________________________ Has your child ever used or abused medication, illegal drugs, or alcohol? Y N Please check and describe any past, present, or anticipated circumstances in your family.
____________________________ ____ _______________________________ First Name MI Last _____biological mother _____stepmother _____ adopted mother Address (If not living with child) _____________________________________________ Date of birth ________________Occupation __________________________________ Workdays and hours __________________________________ Would you describe your work as stressful? Y N Religious background: ____________________________________________________ Spiritual beliefs:__________________________________________________________ History of learning, emotional, or behavioral problems? Y N (If yes, please explain)
History of alcohol/drug/substance abuse? Y N (If yes, please explain)
______________________________________________________________________ History of domestic violence? Y N (If yes, please explain)
______________________________________________________________________ Current living arrangements: ___Family of origin ___Relatives ___Single
___Married ___Roommate/Significant other(s) Marital Status History (include all that apply and duration of each) Never married ______ Married _____ to ______ Separated ______ to ______ Divorced ______Widowed _____ Married _____ to ______ Separated ______ to ______ Divorced ______Widowed _____ Did you have experiences that felt overwhelming or traumatizing in our life, during childhood
or beyond? (please describe) ______________________________________________
INFORMATION ON CHILD’S FATHER ____________________________ ____ _______________________________ First Name MI Last _____biological father _____stepfather _____ adopted father Address (If not living with child) _____________________________________________ Date of birth _______________ Occupation ___________________________________ Workdays and hours __________________ Would you describe your work as stressful? Y N Religious background: ____________________________________________________ Spiritual beliefs:_________________________________________________________ History of learning, emotional, or behavioral problems? Y N (If yes, please explain)
History of domestic violence? Y N (If yes, please explain)
______________________________________________________________________ Current living arrangements: ___Family of origin ___Relatives ___Single
___Married ___Roommate/Significant other(s) Marital Status History (include all that apply and duration of each) Never married ______ Married _____ to ______ Separated ______ to ______ Divorced ______Widowed _____ Married _____ to ______ Separated ______ to ______ Divorced ______Widowed _____ Did you have experiences that felt overwhelming or traumatizing in our life, during childhood
or beyond? (please describe) ______________________________________________
Do any of these experiences come to your mind regularly now? ___________________ Who are your major resources of support now? ________________________________
General Intake Form completed by: Parent/Guardian Signature ______________________________ Date: _____________
Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 401, Frisco, TX 75034 940-300-1706
PROFESSIONAL DISCLOSURE STATEMENT AND
CONSENT FOR TREATMENT Professional Disclosure Statement
Professional Information: Alexandria Pena is a Licensed Professional Counselor Intern and completed her Master’s of Science in Counseling and Development – Clinical Mental Health at Texas Woman’s University in December 2017.
In her post graduate hours Alexandria gained experiences with adult, child, and adolescent counseling in the private practice setting with issues ranging from but not limited to anxiety, depression, divorce, grief, intimacy issues, autism, brain injuries, self-harm, abuse, and trauma. Alexandria also received training in biofeedback and Child-Centered Play Therapy. In her graduate program, Alexandria completed her internship at Cumberland Family Services and The Play Project where she worked with children, adolescents and adults who had been selected by their schools to receive counseling during school hours, and/or those who faced homelessness, abuse, and other challenges. Alexandria’s bachelor’s degree is in psychology, and she has received additional special training in Child-Centered Play/Person-Centered Therapy while in her Master’s program that she likes to include in her view of the client as a free and capable individual.
Alexandria is also a member of the American Counseling Association, the Association for Play Therapy, and the North Texas Chapter of the Association for Play Therapy.
Philosophy of Counseling:
Counseling can be a scary next step for both children and adults, It is my goal to facilitate and enable clients to find meaning and understanding in life to process, cope, and heal. I like to partner with you in your decision to walk on this healing journey. Problems and issues are many times symptoms of what we have faced, and I would love to provide a consistent, honest, and solid presence for whom you can relate. I accomplish this by using a non-directive, humanistic approach with elements of Client-Centered theory and therapy. There are many options for us to explore as we get to know each other and some of those areas include play therapy, and therapeutic role-play.
Informed Consent
Emergency/Crisis: Please know that Crossroads Child & Family Counseling, PLLC does not provide a 24-hour crisis counseling service. Should you experience an emergency necessitating immediate mental health attention, call 9-1-1 or go to the nearest emergency room for assistance.
Counseling Relationship: During the course of counseling, you and/or your child will meet with Alexandria (also referred to as Alex) for approximately 45-minute sessions. Although sessions may be psychologically intimate, the relationship between client and therapist is professional. Please do not ask me to relate to you in any way other than the professional context of counseling sessions.
Effects of Counseling: At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discounting counseling. While benefits are expected from counseling, specific results are not guaranteed. Counseling is a process of personal exploration and may lead to major changes in your life perspectives and decisions.
These changes may affect significant relationships, your job, and/or your understanding of yourself. Some of these life changes could be temporarily distressing. The exact nature of these changes cannot be predicted. Together we will work to achieve the best possible results for you. Clients Rights Some clients need only a few counseling sessions to achieve their goals; others may require months or even years. As a client, you are in complete control and may end our counseling relationship at any time, though I do ask that you participate in a termination session. You also have the right to refuse or discuss modification of any counseling techniques or suggestions that you believe might be harmful. You are assured that counseling services will be rendered in a professional manner consistent with accepted legal and ethical standards as stipulated by the Texas State Board of Examiners of Licensed Professional Counselors and the HIPAA security and privacy rules. If at any time, for any reason you are dissatisfied with the services at Crossroad Child & Family Counseling PLLC, please let me know so that existing issues can be worked through. If someone is not available to resolve your concerns, you may report your complaint. Referrals: Should you and/or Alex believe that a referral is needed; you will be provided with some alternatives, including programs and/or people who may be available to assist you. Also, should you miss two appointments concurrently for whatever reason; a referral will also be provided. You will be responsible for contacting and evaluating those referrals and/or alternatives. Fees: In return for a fee of $100 per session, Crossroads Child & Family Counseling, PLLC agrees to provide counseling services for you. The original intake session is $120. The fee for each session will be due at the conclusion of each session. The rate for all related counseling services, including but not limited to, time incurred due to phone calls over 5 minutes, medical concerns, psychiatric concerns, home and family social studies, child protective service cases, adoption and foster care, issues of divorce, child custody, attorney consultations, educational concerns, behavioral concerns, ARD meetings, classroom observations, interactions with insurance providers, etc., will be billed at $90 per hour in 15 minute increments. In the case of off-site services, fee includes travel time to and from Crossroads Child & Family PLLC. Checks are payable to, "Crossroads Child & Family Counseling, PLLC.” You may also pay by M/C or Visa. CANCELLATION POLICY: In the event you are unable to keep an appointment, please give notification of 24 hours or more. IF A CANCELLATION OCCURS WITHOUT A 24 HOUR NOTICE OR YOU FAIL TO KEEP YOUR SCHEDULED APPOINTMENT, A REGULAR SESSION FEE WILL BE BILLED TO YOUR CREDIT CARD OR BILLED TO YOU. All returned checks will incur a $25.00 return-check fee. A 5% fee will incur for all credit cards that are declined. If you are absent two weeks in a row without contacting me, you will be provided with other referral sources for further counseling. Likewise, if you are absent three sessions in a row, even with contact, you will provided with other referral sources for a continuation of counseling at a different facility. If you do, at any time, intend to discontinue counseling, please inform me as soon as possible so that other clients can be serviced. Records and Confidentiality: Discussions between a therapist and a client are confidential. No information will be released without the client’s written consent unless mandated or permitted by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in treatment facilities; sexual exploitation; AIDS/HIV and other communicable disease infection and possible transmission; court orders, criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn, protect, notify or disclose; sexual exploitation by a mental health professional or member of the clergy, fee disputes between the therapist and the client; a negligence suit brought by the client against
the therapist; the filing of a complaint with a licensing board or other state or federal regulatory authority; to regulatory authorities in connection with their compliance or investigatory responsibilities; to employees or agents of the practice for operational purposes, to a supervisor if the therapist is under supervision and for treatment consultations with other mental health professional when deemed necessary by the therapist. FOR FURTHER INFORMATION REVIEW THE NOTICE OF PRIVACY PRACTICES FURNISHED TO YOU BY YOUR THERAPIST IN CONJUNCTION WITH THIS CLIENT INFORMATION AND CONSENT DOCUMENT. By signing this Intake and consent form below you acknowledge receipt of a copy of the Notice of Privacy Practices. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss this matter further. By signing this information and consent form below, you are giving your consent to the undersigned therapist to share confidential information with all persons mandated or permitted by law, with the agency that referred you and the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for those services, and you are also releasing and holding harmless the undersigned therapist for any departure from your right of confidentiality that may result.
Duty to Warn In the event that the undersigned therapist reasonably believes that you are a danger, physically or emotionally, to yourself or another person, by singing this information and consent form below, you specifically consent for the therapist to warn the person in danger and to contact any person in position to prevent harm to yourself or another person, in addition to medical and law enforcement personnel, and the following persons: NAME TELEPHONE NUMBER __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ This information is to be provided at your request for use by said persons only to prevent harm to yourself or another person. This authorization shall expire upon the termination of your therapy with the undersigned therapist. You acknowledge that you have the right to revoke this authorization in writing at any time to the extent the undersigned therapist has not taken action in reliance on this authorization. You further acknowledge that even if you revoke this authorization, the use and disclosure of your protected health information could possibly still be permitted by law as indicated in the copy of the Notice of Privacy Practices of the undersigned therapist that you have received and reviewed. You acknowledge that you have been advised by the undersigned therapist of the potential of the redisclosure of your protected health information by the authorized recipients and that it will no longer be protected by the federal Privacy Rule. You further acknowledge that the treatment provided to you by the undersigned therapist was conditioned on you providing this authorization. Should you or an entity through your signature, request a copy of you or your child’s counseling records, please be aware that a $50.00 record preparation fee will be incurred and a “Release of Records” form must be signed. An overall counseling summary, in lieu of records, may also be provided. A fee of $50 per 15 minutes is charged for preparation time. If records are subpoenaed, this does not indicate an automatic release of records and is at liberty to be quashed should it be deemed not in the client’s best interest. To further protect your Confidentiality, if I see you in public, I will only acknowledge you if you approach me first. Court: It is in your best interest to know that conducting expert witness/testimonial service is not in my area of interest or expertise. I do not agree to serve as an expert witness or to provide
testimonial services for you, and you agree not to cause my services to be used in this way. If you are seeking counseling for court or court-related purposes or motivations, I will provide you with alternative appropriate referral sources. Should you, your attorney, your spouse or ex-spouses attorney, subpoena me or your client file as a factual case witness, or involve me in court-related proceedings, you agree to pay $300.00 for every hour of my time involved, including case preparation, travel, witness time, and any wait time related to a court-related process. You further agree to pay a retainer fee of $2,400.00 at the time a subpoena is served, to be applied toward these charges. If a subpoena is issued for me, it will be turned over to an attorney, and I will consult with an attorney as necessary at your expense. A bill will be rendered to you for immediate payment when a subpoena is issued. If you have a suspicion that your case will be going to court, or you will need therapist testimony, please let me know before a counseling relationship is established, and appropriate referral sources will be provided to you. Please note: 24 hour advanced notice is required if a cancellation occurs related to a court process, including dismissal of case. If a 24-hour notification is not made, a fee of $2,400 will be billed. (8 hrs. @ $300 per hour)
Child Counseling/Play Therapy
Play Therapy Logistics: If a divorce or custody suit has occurred, a copy of the entire divorce decree or court ordered parenting plan, whichever is most current, must be provided before service can be provided. It is our policy to involve both parents in the child’s treatment from the onset of services. In most cases services will not be provided until such time as the both parents have been contacted and invited to participate in the child’s treatment. Furthermore, it is helpful that the therapist is apprised of other existing important documentation, such as other court orders, mental health evaluations, etc. For play therapy, sometimes it may be necessary to end the session early depending upon the following circumstances: the nature of the cleanliness of the playroom, the child’s ability to leave when the session is over, a situation where play therapy could no longer continue (e.g., child gets sick, child breaks several toys, child chooses to leave and not return, etc.), and the need for a parent consultation. Because the session may need to end early at times, please be sure to remain in the waiting room for most of the session. If you choose to leave the waiting area, please notify Alexandria Pena before the session begins. Children in the playroom are not asked to clean the room following the session. The reason for this is as follows: If play is a child’s language and toys are the child’s words; having a child clean up the play room following the session would be analogous to asking the child to clean up his/her emotional world. It would be similar to having an adult take back everything he/she said at the end of the counseling session. This is a unique stipulation to play therapy. Please know we are not advocating this action for other circumstances—only play therapy. When the child greets you in the waiting room following the counseling session, it is best not to ask questions, such as “Did you have fun?” While playing is a natural, pleasurable activity for the child, children in play therapy are involved in playing out problems and emotional struggle and, therefore, at times “playing” may not be so enjoyable. Furthermore, when asked what the child did in play therapy, the child will typically respond, “I played”. This would be similar to asking an adult in counseling what he or she did in the session—“We talked”. Before your child attends play therapy, please take him/her to the bathroom. Play therapy can often be very emotional freeing, causing the child sometimes to have to use the bathroom during therapy. It is helpful if the child goes to the restroom before the session begins. Also, if your child is coming from school and is hungry, please give him/her a snack before therapy starts. Only in rare circumstances will food be provided for a child in play therapy. In such a situation, this will be discussed with the caregiver and added to the treatment plan. Please know that the playroom has a variety of media that can be messy (e.g., easel paints, water-color paints, Play-Doh, clay, water, sand, etc.). Please dress your child in clothes that can tolerate mess or possible stains should the child spill paint on him/her. Also, if your child is allergic to any substance that falls into this realm, it is your responsibility to let the play therapist know so that appropriate modifications can be made for your child.
Email and Text Messages: The undersigned therapist uses and responds to email and text messages only to arrange or modify appointments. Please do not send emails related to treatment or therapy sessions as electronic communications are not completely secure and confidential. Any therapy related questions or issues will not be addressed by the therapist in any electronic communication but will be dealt with during the next therapy session. Any electronic transmissions of information by you are retained in the logs of your service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers. You should know that any emails or texts received from you and any responses sent will become part of the therapy record.
Social Media: Your therapist does not accept friend or contact requests from current or former clients on any social networking sites. Adding clients as friends or contacts on these sites can compromise confidentiality and privacy of both the therapist and the client. It can blur the boundaries of the professional relationship and are not permitted. Any attempt by a client to surreptiously gain access to the therapist’s personal site(s) will be cause for termination of the therapy. Therapist’s Incapacity or Death: You acknowledge that, in the event the undersigned therapist becomes incapacitated or dies, it will become necessary for another therapist to take possession of your’s and child’s file and records. By signing this information and consent form below, you give consent to allowing another licensed mental health professional selected by the undersigned therapist to take possession of each file and records and provide you with copies upon request, or to deliver them to a therapist of your choice. The undersigned therapist will select a successor therapist within a reasonable time and will notify the appointed licensed mental health professional. Video or Audio Recordings: You acknowledge and, by signing this information and consent form below, agree that neither you or the undersigned therapist will record any part of your sessions unless you and the therapist mutually agree in writing that the session may be recorded. You further acknowledge that the undersigned therapist objects to you recording any portion of your sessions without the therapist’s written consent. Defamation: By signing this intake and consent form below you agree that you will not make defamatory comments about the undersigned therapist to others or to post defamatory commentary about the therapist on any website or social media site. In the event that defamatory remarks about the therapist are made by you, or others acting in concert with you, you further consent by signing this intake and consent form below to allowing the therapist to use confidential information necessary to rebut or defend against, or prosecute claims for, the defamation. Parental Involvement: Parental involvement is crucial when counseling children. Alex will meet with you on a regular basis to exchange feedback concerning your child. Most situations require a parent to schedule a parent consultation or family session about every four weeks. (Regular session fees apply.) To better facilitate the play therapy process, a Weekly Child Report form is to be completed and brought to each session. Please make several copies of this form. If you have a specific question or concern that cannot wait until your next parent consultation, please include your question on the Weekly Report Form and Alex will respond as soon as possible. Feedback provided to parents/guardians will include overall play themes for your child. To protect the child’s confidentiality and ensure a therapeutic alliance with your child, discussion on specific play behaviors will not be discussed. However, most certainly at times, it will be necessary to discuss specific play behaviors and what this may mean for your child.
By my signature below, I acknowledge reading and understanding this document, and that any
questions I had about this document were answered to my satisfaction, and that I was furnished
a copy of this document. My signature below acknowledges my agreement with and commitment
to comply with all its terms and requirements including the financial obligations and cancelation
policy, and my consent for Alexandria Pena, MS, LPC-Intern: Supervised by Patti Doumany,
MEd, LPC-S, RPT-S to provide counseling or play therapy services to me and/or my child. _______________________________________________ __________________ Client / Guardian Signature Date _______________________________________________ __________________ Counselors Signature Date
Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 401, Frisco, TX 75034 940-300-1706
COURT TESTIMONY AGREEMENT
_____ I am seeking counseling for court testimony or court involvement on behalf of Alexandria Pena, MS, LPC-Intern: Supervised by Patti Doumany, MEd, LPC-S, RPT-S. _____ I am NOT seeking counseling for court testimony or court involvement on behalf of Alexandria Pena, MS, LPC-Intern: Supervised by Patti Doumany, MEd, LPC-S, RPT-S. _____ I have been requested by Alexandria Pena, MS, LPC-Intern: Supervised by Patti Doumany, MEd, LPC-S, RPT-S to provide the most recent court papers concerning my child. It is in your best interest to know that conducting expert witness/testimonial service is not in my area of interest or expertise. I do not agree to serve as an expert witness or to provide testimonial services for you, and you agree not to cause my services to be used in this way. If you are seeking counseling for court or court-related purposes or motivations, I will provide you with alternative appropriate referral sources. Should you, your attorney, your spouse or ex-spouses attorney, or any other person subpoena me or your client file as a factual case witness, or involve me in court-related proceedings, you agree to pay me $300.00 for every hour of my time involved, including case preparation, travel, witness time, and any wait time related to a court-related process. You further agree to pay a retainer fee of $2,400.00 at the time a subpoena is served, to be applied toward these charges. If a subpoena is issued for me, it will be turned over to an attorney, and I will consult with an attorney as necessary at your expense. A bill will be rendered to you for immediate payment when a subpoena is issued. If you have a suspicion that your case will be going to court, or you will need therapist testimony, please let me know before a counseling relationship is established, and appropriate referral sources will be provided to you. Please note: 24 hour advanced notice is required if a cancellation occurs related to a court process, including dismissal of case. If a 24-hour notification is not made, a fee of $2,400 will be billed. (8 hrs. @ $300 per hour) By your signature below, you are indicating that you read and understood this document, or that any questions you had about this document were answered to your satisfaction. Client’s Signature: ___________________________________ _________________ Date __________________________________________________ _________________
Alexandria Pena, MS, LPC-Intern Supervised by Patti Doumany, MEd, LPC-S, RPT-S Date
Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 401, Frisco, TX 75034 940-300-1706
CONSENT FOR DISCLOSURE OF INFORMATION
I, ______________________________, hereby provide authorization for Alexandria Pena, MS, LPC-Intern supervised by Patti Doumany, MEd, LPC-S, RPT-S, to obtain and /or provide the following information: __________________________________________________________________________________________________________________________________________________________________________
To / From To / From The following parties/agencies
______________________________ Crossroads Child & Family Counseling, PLLC Agency Name ______________________________ Alexandria Pena, MS, LPC-Intern, Supervised by Contact Name Patti Doumany, MEd, LPC-S, RPT-S ______________________________ 3550 Parkwood Blvd. Suite 401 Address ______________________________ Frisco, TX 75034 City, State, Zip Code ____________________________________ Fax # ____________________________________
Phone # I acknowledge that I have the right to revoke this authorization in writing at any
time to the extent a provider has not taken action in reliance on this authorization. I acknowledge the potential of redisclosure of my protected health information by the authorized recipients and that it will no longer be protected by the federal Privacy Rule.
I further acknowledge that no treatment has been provided to me conditioned on my signing this authorization. ________________________________________________ ___________________ Client Date ________________________________________________ ___________________ Parent/Guardian Date ________________________________________________ ___________________ Alexandria Pena, MS, LPC-Intern: Supervised by Patti Doumany, MEd, LPC-S, RPT-S Date
Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 401, Frisco, TX 75034 940-300-1706
CONSENT FOR DISCLOSURE OF INFORMATION / SCHOOL I, ______________________________________________ hereby provide authorization for Alexandria Pena, MS, LPC-Intern: Supervised by Patti Doumany, MEd, LPC-S, RPT-S, to obtain and/or provide the following information concerning: _______________________________________________ ____________________ (child’s name) (child’s date of birth) _____ Consultation with school personnel regarding academic, social, behavioral, and mental
health observations.
_____Special Education Records _____ Discipline Records To / From To / From The following parties/agencies:
_______________________________ School Name __________________________________ Contact Name __________________________________ Address __________________________________ City, State, Zip Code _______________________________
Fax # _______________________________
Phone #
I acknowledge that I have the right to revoke this authorization in writing at any time to the extent a provider has not taken action in reliance on this authorization. I acknowledge the potential of redisclosure of my protected health information by the authorized recipients and that it will no longer be protected by the federal Privacy Rule.
I further acknowledge that no treatment has been provided to me conditioned on my signing this authorization. ___________________________________________ ___________________________ Parent/Guardian Date ___________________________________________ __________________________ Alexandria Pena, MS., LPC-Intern Supervised by Patti Doumany, MEd, LPC-S, RPT-S Date
Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 401, Frisco, TX 75034 940-300-1706
Informed Consent To Videotape - Parent My signature below confirms that conditions of my consent to be videotaped have been explained to me, and I understand the following: _____ I understand viewing of the tape is for the sole purpose of professional development, supervision, and/or training. Only my child’s first name will be used, or will not be mentioned; the contents of the tape will remain confidential within the educational, training or supervision site. _____ I can withdraw my permission at any time during or after the session. My access or my child’s access to counseling services will not be affected by my decision not to consent to videotaping. _____The tape will be erased or destroyed upon completion of the professional development, supervisory and/or training review of this session. _____ The original copy of this consent form will be kept in my child’s records with Crossroads Child & Family Counseling, PLLC. or: _____ I do not want my child’s sessions to be videotaped and I am under no obligation to have counseling sessions recorded. ________________________________________________ __________________ Signature of Client Date ________________________________________________ __________________ Signature of Parent/Guardian if Client is under 18 Date ________________________________________________ __________________ Signature of Therapist Date
CREDIT CARD AUTHORIZATION FORM Authorizing form granting Crossroads Child & Family Counseling PLLC permission to process credit/debit charges This form is requested for all clients and required to be left on file. Client Names 1. 2.
3. 4.
Please read all below: Acceptable forms of payment are: cash, check, debit card, or credit card
My initials below indicate the following:
Initial here if you would like to pay session fees with your credit or debit card.
Initialing here indicates you authorize Crossroads Child & Family Counseling, PLLC to be compensated for missed appointments of which the client/s named above did now show up for or cancel at least 24 hours before the time of the appointment. Missed appointment fees are the same for all clients at the standard rate of $90 per session. Initial here if you would like to pay session fees by check
Please complete all of the information below Type of card (circle) VISA MC AMX
Exact name on card
Number on card
Expiration Date ________________________________ CVC ______________
Billing address
_______________________________________________ City State Zip Code
Without my debit/credit card, I authorize Crossroads Child and Family Counseling, PLLC to use my credit/debit card number provided below to process charges/fees assigned to any named individual listed above.
My signature below acknowledges my agreement with and commitment to comply with the terms and requirements of the financial obligations and cancelation policy.
Signature ____________ ___ Date _____
The security of your personal information is extremely important. Crossroads Child & Family Counseling, PLLC is committed to protecting the security and privacy of any personal information you provide, including any financial information. Please inquire of any questions concerning this authorization.
Notice of Privacy Practices of Crossroads Child & Family Counseling, PLLC
Effective January 1, 2015
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I am required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of your privacy rights and my legal duties and privacy practices with respect to your PHI. I am required to abide by the terms of this notice with respect to your PHI but reserve the right to change the terms of this notice and make the new notice provisions effective for all PHI that I maintain. I will provide you with a copy of the revised notice sent by regular mail to the last address you have provided to me for this communication purpose.
UNDERSTANDING YOUR PERSONAL HEALTH INFORMATION
Each time you visit a hospital, physician, mental health professional or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, in the case of a mental health professional, psychotherapy notes, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
•Basis for planning your care and treatment. •Means of communication among the many health professionals who contribute to your care. •Legal document describing the care you received. •Means by which you or a third-party payer can verify that services billed were actually provided a tool in educating heath
professionals. •A source of data for medical research. •A source of information for public health officials charged with improving the health of the nation a source of data for
facility planning and marketing. •A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to:
•Ensure its accuracy. •Better understand who, what, when, where, and why others may access your health information. •Make more informed decisions when authorizing disclosure to others.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of my practice, the facility that compiled it, the information belongs to you. You have the following privacy rights:
1.The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment or health care operations.
You should note that I am not required to agree to be bound by any restrictions that you request but am bound by each restriction that I do agree to.
2.In connection with any patient directory, the right to request restrictions on the use and disclosure of your name, location at this treatment facility, description of your condition and your religious affiliation. (I do not maintain a patient directory.)
3.To receive confidential communication of your PHI unless I determine that such disclosure would be harmful to you. 4.To inspect and copy your PHI unless I determine in the exercise of my professional judgment that the access requested is
reasonably likely to endanger your life or physical safety (Note: if state law allows, “emotional safety” may be included as well) or that of another person.
You may request copies of your PHI by providing me with a written request for such copies. I will provide you with copies within ten (10) business days of your request at my office. You will be charged $.25 for each page copied and you will be expected to pay for the copies at the time you pick them up.
5.To amend your PHI upon your written request to me setting forth your reasons for the requested amendment. I have the right to deny the request if the information is complete or has been created by another entity.
I am required to act on your request to amend your PHI within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you. If I deny your requested amendment I will provide you with written notice of my decision and the basis for my decision. You will then have the right to submit a written statement disagreeing with my decision which will be maintained with your PHI. If you do not wish to submit a statement of disagreement you may request that I provide your request for amendment and my denial with any future disclosures of your PHI.
6.Upon request to receive an accounting of disclosures of your PHI made within the past 6 years of your request for an accounting. Disclosures that are exempted from the accounting requirement include the following:
•Disclosures necessary to carry out treatment, payment and health care operations. •Disclosures made to you upon request. •Disclosures made pursuant to your authorization. •Disclosures made for national security or intelligence purposes. •Permitted disclosures to correctional institutions or law enforcement officials. •Disclosures that are part of a limited data set used for research, public health or health care
operations. I am required to act on your request for an accounting within sixty (60) days but this deadline may be extended for another
thirty (30) days upon written notice to you of the reason for the delay and the date by which I will provide the accounting. You are entitled to one (1) accounting in any twelve (12) month period free of charge. For any subsequent request in a twelve (12) month period you will be charged $_______ for each page copied and you will be expected to pay for the copies at the time you pick them up.
7. To receive a paper copy of this privacy notice even if you agreed to receive a copy electronically. 8. To pay out-of-pocket for a service and the right to require that I not submit PHI to your health plan. 9. To be notified of a breach of your unsecured PHI. 10. If your records are electronically maintained, the right to receive a copy of your PHI in an electronic format and to direct
in writing that a third party receive a copy of your PHI in an electronic format. 11.The right to complain to me and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you
believe your privacy rights have been violated. You may submit your complaint to me in writing setting out the alleged violation. I am prohibited by law from retaliating against you in any way for filing a complaint with me or HHS.
Uses and Disclosures
Your written authorization is required before I can use or disclose my psychotherapy notes which are defined as my notes documenting or analyzing the contents of our conversations during our counseling sessions and that are separated from the rest of your clinical file. Psychotherapy notes do not include medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date. It is my policy to protect the confidentiality of your PHI to the best of my ability and to the extent permitted by law. There are times however, when use or disclosure of your PHI including, psychotherapy notes, is permitted or mandated by law even without your authorization. Situations where I am not required to obtain your consent or authorization for use or disclosure of your PHI psychotherapy notes include the following circumstances:
•By myself or my office staff for treatment, payment or health care operations as they relate to you.
For example: Information obtained by me will be recorded in your record and used to determine the course of treatment that should work best for you. I will document in your record our work together and when appropriate I will provide a subsequent counselor or health care provider with copies of various reports that should assist him or her in treating you once we have terminated our therapeutic relationship.
For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
•In the event of an emergency to any treatment provider who provides emergency treatment to you. •To defend myself in a legal action or other proceeding brought by you against me. •When required by the Secretary of the Department of Health and Human Services in an investigation to determine my
compliance with the privacy rules. •When required by law in so far as the use or disclosure complies with and is limited to the relevant requirements of such law.
Examples: To a public health authority or other government authority authorized by law to receive reports of child abuse or neglect.
If I reasonably believe an adult individual to be the victim of abuse, neglect or domestic violence, to a governmental authority, including a social services agency authorized by law to receive such reports to the extent the disclosure is required by or authorized by law or you agree to the disclosure and I believe that in the exercise of my professional judgment disclosure is necessary to prevent serious harm to you or other potential victims. If I make such a report I am obligated to inform you unless I believe informing the adult individual will place the individual at risk of serious injury. In the course of any judicial or administrative proceeding in response to:
•An order of a court or administrative tribunal so long as only the PHI expressly authorized by such order is disclosed, or •A subpoena, discovery request or other lawful process, that is not accompanied by an order of a court or administrative
tribunal so long as reasonable efforts are made to give you notice that your PHI has been requested or reasonable efforts are made to secure a qualified protective order, by the person requesting the PHI.
•Child custody cases and other legal proceedings in which your mental health or condition is an issue are the kinds of suits in which you PHI may be requested.
•In addition I may use your PHI in connection with a suit to collect fees for my services. •In compliance with a court order or court ordered warrant, or a subpoena or summons issued by a judicial officer, a grand
jury subpoena or summons, a civil or an authorized investigative demand or similar process authorized by law provided that the information sought is relevant and material to a legitimate law enforcement inquiry, the request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought and de-identified information could not reasonably be used.
•To a health oversight agency for oversight activities authorized by law as they may relate to me (i.e., audits; civil, criminal or administrative investigations, inspections, licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions).
•To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law.
•To funeral directors consistent with applicable law as necessary to carry out their duties with respect to the decedent. •To the extent authorized by and the extent necessary to comply with laws relating to workers compensation or other similar
programs established by law. •If use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the
public and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
•To a public health authority that is authorized by law to collect or receive such information for the purposes of preventing or controlling a disease, injury or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth, death, and the conduct of public surveillance, public health investigations, and public health interventions.
•To a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if the covered entity or public health authority is authorized by law to notify such persons as necessary in the conduct of a public health intervention or investigation.
•To a public health authority or other appropriate governmental authority authorized by law to receive reports of child abuse or neglect.
•To a law enforcement official if I believe in good faith that the PHI constitutes evidence of criminal conduct that occurs on my premises.
•Using my best judgment, to a family member, other relative or close personal friend or any other person you identify, I may disclose PHI that is relevant to that person’s involvement in your care or payment related to your care.
•To authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by the National Security Act and implementing authority.
•To Business Associates under a written agreement requiring Business Associates to protect the information. Business Associates are entities that assist with or conduct activities on my behalf including individuals or organizations that provide legal, accounting, administrative, and similar functions.
•To family members and others involved in your care prior to your death, unless doing so would be inconsistent with any prior expressed preferences you made known to me, but limited to PHI relevant to the family member or other person’s involvement in your care or payment.
I may contact you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. If you have any questions and would like additional information you should bring this to my attention at the first opportunity. I am the designated Privacy Officer for my practice and will be glad to respond to your questions or request for information.
Client Consent Form
I understand that as part of my health care, the undersigned therapist originates and maintains health records describing my health history, symptoms, evaluations and test results, diagnosis, treatment, psychotherapy notes, and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other health care providers and other routine health care operations such as assessing quality and reviewing competence of health care professionals. The Notice of Privacy Practices for CROSSROADS CHILD & FAMILY COUNSELING, PLLC, provides specific information and a thorough description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and I have been given the opportunity to review the notice prior to signing this consent. Before implementation of any revised Notice of Privacy Practices, the revised Notice will be mailed to me at the address I designate below. I understand that I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or health care operations and that I am not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that CROSSROADS CHILD & FAMILY COUNSELING, PLLC has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing.
I request the following restrictions on the use and/or disclosure of my personal health information:
Therapist response: Agree to restriction/Do not agree to restriction ____________________________________________________________________________ I further understand that any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law. I have been provided and have received Alexandria Pena, MS, LPC-Intern: Supervised by Patti Doumany, MEd, LPC-S, RPT-S Notice of Privacy Practices dated January 1, 2015. Signature of Client or Legal Representative: ______________________________________________________________ _____________________ (Full Name) Date Signature of Client or Legal Representative: ______________________________________________________________ _____________________ (Full Name) Date I request that changes to the Notice of Privacy Practices be sent to me at this address: ________________________________________________ ________________________________________________ ________________________________________________ Witnessed: _____________________________________________________ _____________________ Crossroads Child & Family Counseling, PLLC Date
Crossroads Child & Family Counseling, PLLC 3550 Parkwood Blvd. Suite 401, Frisco, TX 75034 940-300-1706
WEEKLY REPORT
Please make copies of this form and bring completed to each counseling session. Counselor will not discuss child’s sessions in the waiting room. Parent consultations are recommended every
4 weeks, but may be scheduled as often as needed. It is the parents/guardians’ responsibility to schedule consultations. Child’s Name: ____________________________________ Date: _______________
1. Week Rating of Behavior (1 = NOT stressful compared to last week: 10=VERY
stressful compared to last week)
1 2 3 4 5 6 7 8 9 10 2. Reason(s) for choosing the number above (i.e., specific behaviors that occurred)
3. Any new changes/happenings this week (i.e., can be small changes for your child, such as he/she had a sore throat, a parent worked longer hours this week—or can be significant changes for your child, such as a pet dying, car wreck, etc.)
4. New Behaviors Noticed: 5. Medication: Not Applicable No Change Change: 6. Something positive your child did this week that either surprised you or impressed
you: 7. Other Concerns or Questions? 8. I would like to schedule a parent consultation. Y N
Crossroads Child & Family Counseling 3550 Parkwood Blvd. Suite 401, Frisco, TX 75034
Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communication
Patients in our practice may be contacted via email or text messaging to be reminded of an upcoming appointment, or to provide general information. If at anytime I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other information at that email or text address from Crossroads Child & Family Counseling, PLLC. I __________________________________consent to receive text messages from Crossroads Child & Family Counseling, PLLC at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders or other health information unless I request a change in writing (See revocation section below).
The cell phone number that I authorize to receive text messages for appointment reminders and general health information is ____________________________________________. The email that I authorize to receive text messages for appointment reminders and general health information is _____________________________________________________________. _____ (Your initials) By providing my cell phone number and/or email address, I am giving the staff at Crossroads Child & Family, PLLC permission to contact me via text and/or email. Crossroads Child & Family Counseling, PLLC does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (Contact your carrier for pricing plans and details).
Revocation _____ I hereby revoke my request for future communications via email. _____ I hereby revoke my request for future communications via text messages.
_____ I hereby revoke my request to receive any future appointment reminders, and general health information via email. _____ I hereby revoke my request to receive any future appointment reminders, and general health information via text messages. Note: This revocation only applies to communications from Crossroads Child & Family Counseling, PLLC.
